You May be Right I May Be Crazy

The word “may” in the title to this Billy Joel song is the operative word, and as we are perched on the cusp of the newest edition of the Diagnostic and Statistical Manuel of Mental Disorders (DSM) the “mayness” of the matter should be foremost in mind.

The information I’m sharing comes from a Time magazine article by John Cloud entitled “What Counts as Crazy?” on pages 42 – 45 of the March 19, 2012 issue. For the record there have been four editions of the DSM. The first was published in 1952; the second was published in 1968, the third in 1980, the fourth in 2000, and the fifth is scheduled for publication in 2013 (44).

The editions, according to Cloud, differ as follows. The 1952 edition “Codified Freudian ideas. Depression was seen as a reaction to early stressors. The book relied largely on the experiences of service members who had returned from World War II” (45). The 1968 edition “Described a gap between ‘neurosis’ and ‘psychosis’ both became popular terms. Although new drugs had been developed to treat mental illness, DSMII still used older nomenclature.” The paradigm shift really happened between 1952 and 1980. Freud was losing influence and behaviorist Skinner was gaining. The later “believed psychology should be grounded in clinical trials.” The former believed in “therapy sessions with no definable end points” (44, emphasis mine). The 1980 edition “Departed from earlier editions to define diagnoses by lists of symptoms rather than causes. Defining mental illness by symptoms rather than causes led to a dramatic increase in diagnoses (45). The 2000 edition “Refined the symptom-based method with new science but kept old diagnoses like ‘fetishism.’ [It] “created a jarring mix of new neuroscience and old Freudian diagnoses, for which aging psychologists still want to bill insurers” (45).

The author doesn’t speak as a pastor, theologian, or therapist, but he is “disturbed” in some sense at the power the DSM exercises in our lives. For example in speaking of the Decision Trees for Differential Diagnosis that is in the back of the DSM he says things like this: “Vague words like expansive can lead psychologists to pathologize normal behavior” (42). You have a “hypomanic episode” if you have an “Elevated, expansive, or irritable mood, of at least 4-day duration.” Cloud observes, “The DSM can also seem [?] arbitrarily precise. Why is the cutoff four days, not three or five” (42)? When you get to the end of the decision tree for diagnosis of mood disorders you have the block “Depressive Disorder NOS.” Cloud comments, “NOS means ‘not otherwise specified,’ which means virtually any behavior can be called an illness” (43).

This worry, this fear, or perhaps in Cloud it’s no more than a passing cloud, shows up time an again in the article. He says this new edition “will literally redefine what’s normal” (44). For example, “The new definition of depression would eliminate a current exception for bereavement, meaning those mourning the loss of a loved one could be diagnosed with an illness” (44). Cloud all but boils to a thunderhead when speaking of the American Psychiatric Associations’ proposed adding of binge-eating disorder. He says that “it would be defined, in part, with an imprecision bordering on absurdity: eating ‘an amount of food that is definitely larger than most people would eat” (44). By this standard every teenage boy has an eating disorder.

Christians in general and pastors in particular don’t really see how profoundly this little book has impacted them. Up until the 1980 edition homosexuality was classified as a mental illness. But then “Being gay was deemed sane by a vote of 5,854 to 3,810” (44). What most of us don’t know is “mental-health diagnosis remains as much art as science” (44). In this vein the Canadian Journal of Psychiatry concluded, “’not one single laboratory marker has been shown to be diagnostically useful for making a DSM diagnosis’” (45).

What is also not to be missed by everyone is the impact DSM has on healthcare costs. I asked the Concordia Health Plans to break out psychiatric/ psychology coverage from the ordinary medical care. They admitted premiums would be much cheaper, but they refused to give that option. Right now there are 350 diagnoses in the 2000 DSM edition. The number of psychiatric diagnoses that were in the first 1917 manual was 22. Cloud observes, “What DSM 5 almost certainly will do is help APA members bill insurance companies for more conditions” (45).

The DSM may be right; I may be crazy, but then again I may not be. Then, too, to paraphrase the words of Billy Joel: I just might be the lunatic they’relooking for.